SSM Health, community partners dedication to addressing community health needs

SSM Health, in collaboration with several community partners across Fond du Lac County, recently hosted a UniteUs site visit at SSM Health St. Agnes Hospital to strengthen coordinated care efforts for patients and families facing complex social and health needs.

The event in mid-June reflected the commitment by many community organizations who have been instrumental in this initiative, including ADVOCAP, Charis Pregnancy and Family Help Center, St. Katherine Drexel Shelter, Solutions Center, Holy Family Warming Shelter, Fondy Food Pantry, and Fond du Lac County Health Department’s Save A Smile program, along with SSM Health’s Samaritan Clinic and Case Management teams.

Through demonstrations and collaborative discussions, participants explored how the UniteUs platform can enhance communication between health care providers and social service organizations – ensuring individuals that are experiencing homelessness, food insecurity, or other challenges receive timely and appropriate care.

“Providing the right care at the right time is essential to improving health outcomes,” according to Laura Nakielski, SSM Health community health manager. “While this tool will not only help us better serve our unhoused patients and get them the care they need, it will also serve those that are in most need of our love and support.”

SSM Health Samaritan Clinic and Case Management teams played a key role in the event, demonstrating how integrated care coordination supports both medical and social needs, particularly for vulnerable populations.

Community partners emphasized the importance of shared systems in delivering effective care. “This initiative of UniteUs and SSM Health, with Samaritan Clinic, will help our shelter know what our clients have already received and allow us to support them in getting the additional care they need,” says Amy Loof, St. Katherine Drexel Shelter executive director.

The Charis Pregnancy and Family Help Center, a nonprofit organization supporting pregnant women and families, also underscored the value of collaborative care. “We are incredibly grateful for this opportunity,” Paige Kelley, Charis executive director, shares. “This ability to coordinate services ensures that staff take care of their patients’ social and family needs, knowing their medical needs are being appropriately managed.”

ADVOCAP – an organization with programs focused on housing stability, basic needs, childhood development, workforce opportunities, and supporting older adults – is a critical partner in the broader network, helping connect individuals to a wide range of resources and services.

This initiative reflects SSM Health’s continued commitment to addressing all aspects of health and working alongside community partners to build stronger systems of care beyond hospital walls.